Refer to: Loeffel ED, Watson W: Screening for skin cancer at a county fair. West J Med 122:123-126, Feb 1975
Screening for Skin Cancer at a County Fair E. DORINDA LOEFFEL, MD, Chicago, and WILLIAM WATSON, MD, Stanford
Six skin cancer detection clinics were held at a county fair booth in Turlock, California during August, 1973. Examination of sun-exposed skin areas in 605 people showed potential skin cancer in 28.6 percent of people 25 years of age or older. Of the people examined, 135 were referred to their own physicians for follow-up diagnosis and treatment of skin lesions. EARLY RECOGNITION and successful treatment of skin cancer is a realistic goal, given the visibility of early malignant skin lesions and the ease of rapid diagnostic confirmation through skin biopsy. Diagnostic delay of the "sore that won't heal" seems inexcusable, but understandable, due to lack of pain coupled with cosmetic indifference, personal neglect and fear of going to a physician's office. General ignorance about skin cancer, transportation problems for geriatric patients and lack of convenient health care facilities also probably contribute to delay in diagnosis. To counteract such difficulties, efforts have been made in several areas of the country to "reach" people by taking cancer-detection units to unusual places. In Nebraska, a mobile house trailer with special examination rooms and x-ray equipment is used in screening geriatric patients for skin cancer as well as cancer of the mouth, larynx, breast, lung, uterus and colon.' In Virginia, several Saturday clinics have been held in rural areas for detection of skin and oral cancer among farmers.2 In North Carolina, a skin cancer detection clinic was operated at the 1972 State Fair, with special emphasis on educating large numbers of people From the Department of Dermatology, Stanford University Medical Center, Stanford. Submitted July 9, 1974. Reprint requests to: W. Watson, MD, Department of Dermatology, Stanford University Medical Center, Stanford, CA 94305.
about the dangers to skin of excessive sunlight ex-
posure.3 Most of these programs have depended on physician volunteers, along with promotional, organizational and financial support from the American Cancer Society. In August, 1973, a pilot skin cancer screening booth sponsored by the American Cancer Society and the National Program for Dermatology was operated for six days at the Stanislaus County Fair in Turlock, California. Turlock is a community of 14,000 people located in the hot, fertile San Joaquin Valley and serving a surrounding population of farmers and ranchers at very high risk for developing skin cancer. An estimated 50,000 people attend the fair at Turlock every year, so that detection of a large number of people with skin cancer could be anticipated if visitors to the fair could be persuaded to undergo skin examinations. Attention was drawn to the booth in advance through newspaper articles and contact with the Stanislaus County Medical Society. Posters, pamphlets and an audiovisual program about cancer detection helped to advertise the location of the booth. Cancer Society volunteers giving friendly reassurance that examinations were quick, free and painless helped popularize the booth. Skin examinations were done by five physicians from the Stanford University Dermatology DeTHE WESTERN JOURNAL OF MEDICINE
123
SCREENING FOR SKIN CANCER
Date
Name
middl e i niti al
Fi rst
Last
Address
Sex Age Occupation_
Phone
Birthplace_
Number of years lived in California
Race
Previous skin cancer
yes
no
Usual physican and address
Presumptive diagnoses (check and locate 1. 2. 3. 4. 5. 6. 7. 8.
on
anatomical diagram)
Actinic keratosis Basal cell carcinoma Squamous cell carcinoma Leukoplakia Bowen's Disease Melanoma Normal skin Other (specify)
-
Ccf R1 1'
Degree of actinic damage:
Z--t_
C~~~~~~~
mild moderate severe Examiner
Figure 1.-Registration form used in skin cancer screening booth.
Physician notified of abnormal skin findings by American Cancer Society on
(date) American Cancer Society Booth Stanislaus County Fair Turlock, California August 6-11, 1973
partment working on different evenings. A tiny examining room was formed with portable screens surrounding a single chair, goose-necked lamp and small cabinet. Only sun-exposed skin areas (face, neck, upper chest, arms and hands) were examined in most cases, so that it was not necessary for clothing to be removed. Other skin areas were examined upon request. The average examination took two to three minutes, with less time for children and longer times for complicated problems. TABLE 1.-Checklist Used in Making Presumptive Diagnosis 1. 2. 3. 4.
Actinic keratosis Basal cell carcinoma Squamous cell carcinoma Melanoma
124
5. Leukoplakia 6. Bowen's disease 7. Normal skin 8. Other (specify)
FEBRUARY 1975 * 122 * 2
Records were kept on cards filled in both by the physician and by the person being examined (Figure 1). After the visitor supplied personal information, the physician estimated the degree of sun damage (none, mild, moderate, severe) and checked off a presumptive diagnosis from a list of seven common lesions (Table 1). The location of suspicious lesions was noted on an anatomical sticker pasted to the card. Later, the presumptive diagnosis and the location of the lesion were recorded on a postcard that was mailed to the patient's usual physician. The postcard also contained an explanation: "Your patient was recently screened for skin cancer in the American Cancer Society Booth at the Stanislaus County Fair in Turlock. Abnormal findings were called to the
SCREENING FOR SKIN CANCER
= E
total number of patients examined per 5 year age span number of positive examinations for presumptive malignant and premalignant skin lesions
25
20
la 7E x
0
at
S
@a 10
0
P.
Si)
0
In
0
0.
S
S)
.
.0
0
in E
0
C
i
Vth
/
V(
VeVet
/VfV{
20 30 40 50 60 7o0 80 90 age range in years Figure 2.-Distribution by age of normalland abnormal examination results in men. 10
0
50
la
40 .
c
E x
30 b
0) 0
-
20
0
IN 0 .0
CY CY
E 10
t-
a-
$o
Male
one
di I
Ie 10
zd2&/ZVZZ4'ZIA
Results Community response to the booth was generally favorable, with most visitors expressing appreciation for the time and effort given by volunteers. Many people sought advice for specific skin problems, while others came because of curiosity or a desire to please a concerned spouse. A few people questioned the program's legitimacy and motives. Several also requested that records not be sent to their physicians, apparently from fear of offending them. A few physicians in the area opposed the booth on the principle that it represented "curbstone" medicine. Skin examinations were done on 605 people, including 222 men and 383 women, ranging in age from 3 to 89 years old. Distribution of normal and abnormal results of the examinations by sex and age group is shown in Figures 2 and 3. While 370 people had normal skin and 85 more had only minor skin problems, 149 had significant skin problems deserving medical attention. Of these 149 people, 135 were eventually referred for treatment to their personal physicians. In 14 cases, information was too incomplete to enable referral. Presumptive diagnosis of malignant and premalignant skin lesions was made in 125 people, including 63 men and 62 women, ranging in age from 25 to 89 years. Suspicious lesions included basal cell carcinoma in 49, squamous cell carcinoma or possible Bowen's disease in 11, leukoplakia in 8 and actinic keratosis in 88 people. Table 2 shows the exact distribution of lesions by sex. Most lesions were on sun-exposed areas, although one basal cell carcinoma and two squamous cell carcinomas were seen on legs. Leukoplakia was detected only on lower lips, as complete oral examinations were not attempted. Two types of potential skin cancer were present in 31 people, with actinic keratoses occurring together with TABLE 2.-Presumptive Clinical Diagnosis of Malignant and Premalignant Skin Lesions
at C
attention of the patient, who will hopefully contact you for advice in the near future. Additional information is available in our Modesto office."
Do E
L
20 30 40 50 60
70
so
90
age range in years Figure 3.-Distribution by age of normal and abnormal examination results in women.
Basal cell carcinoma ......... 24 Squamous cell carcinoma and Bowen's disease ........... 5 Leukoplakia ................ 7 Actinic keratoses* ........... 48
Female
Total
25
49
6 1 40
11 8 88
* In 31 people, actinic keratoses occurred along with basal cell carcinoma (19), squamous cell carcinoma (8) and leukoplakia (4).
THE WESTERN JOURNAL OF MEDICINE
125
SCREENING FOR SKIN CANCER TABLE 3.-Significant Nonmalignant Skin Lesions Age/Sex
6
Presumptive Diagnosis
9
15 9 19 19
9 9 9
20 20 9 23 24 26 30 43 46 47 59
9 9 9 9 9 9 9 9 59 9 61 9 62 9 62 64 99 69 71 99 75
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Dermatophyte infection-cheek Atopic hand eczema Irritated nevi on back Acne and tinea versicolor Tinea versicolor Nickel allergy and "mole"on labia (not examined) Irritated nevi on back Chloasma Seborrheic dermatitis-postauricular Bleeding nevus Syringomas Lichen simplex chronicus-forearm Xanthelasma
Xanthelasma Red nodule-tongue Giant skin tag vs. neurofibroma Blue nevus-forehead Stasis dermatitis Xanthelasma Flesh-colored papule-cheek Violaceous nodules-forearm Hutchinson's freckle vs. senile lentigo
basal cell carcinoma, squamous cell carcinoma or leukoplakia. The youngest age at which each type of lesion was detected was 25 for basal cell carcinoma, 28 for actinic keratosis, 39 for squamous cell carcinoma and 40 years old for leukoplakia. Grouping of lesions into five-year age groups showed peaks at age 45 to 50 for men and age 60 to 65 for women (Figures 2 and 3). No malignant or premalignant lesions were seen in people younger than 25 years of age. No melanomas were detected. Significant nonmalignant skin lesions were found in 22 people (Table 3) who therefore were referred for treatment. These included 21 women. Nine lesions were felt to warrant skin biopsy to enable exact identification.
Discussion Previous skin cancer detection clinics in Virginia and North Carolina had overall detection rates of 21.6 percent and 37.8 percent respectively.2'3 In this study the overall detection rate for potential skin cancer was 20.6 percent. If significant nonmalignant skin lesions were included, the detection rate increased to 24.3 percent. Therefore, almost one out of four skin examinations produced a significant finding. For people 25 years of age and older, the effective cancer detection rate was 28.6 percent, or 125 out of 438 examinations. Since no potentially malignant skin lesions 126
FEBRUARY 1975
*
122
*
2
were found under age 25, exclusion of the younger age group would seemingly save time and be medically safe except for melanoma detection. However, this might greatly hamper instruction of young persons about the hazards of sunlight and the value of protective clothing and sunscreens. Such advice is particularly important for Causasions with red or blonde hair, blue eyes and fair complexions-who form the group most at risk for developing skin cancer.4 No attempt was made in this study to verify presumptive diagnoses or trace individual followup treatment. While such measures are necessary to assure proper care and firm statistics, they require a great deal of volunteer time, perseverance and effort. It was hoped in this project that individual patients would take responsibility for seeking medical care and that physicians in the area would willingly examine and treat skin lesions called to their attention. Future skin cancer screening programs should probably limit examinations to people 25 years old or older, except for evaluation of specific skin problems such as changing "moles" in younger persons. Education about skin cancer and its relationship to prolonged sun exposure could perhaps be carried out in an adjacent area by a physician not involved in making examinations. Distribution of free sunscreen samples, as done at the North Carolina State Fair, would probably help draw visitors to the booth. Detection of oral cancer could easily be added to such a program, providing that sufficient space were available to accommodate a dental examination chair and proper light source. The benefits of such screening programs should be substantial, with early detection of skin cancer leading to prolongation of life and reduction of future required medical care. Possibly, the greatest long-term benefit could be cancer prevention through mass education concerning the hazards of prolonged sun exposure and the usefulness of sunscreens. Additional benefits to participating volunteers include the personal satisfaction of useful community service and the enjoyment of friendly interaction with local residents in a relaxed environment. REFERENCES 1. Lynch H, Lynch J, Kraff C: A new approach to cancer screening and education. Geriatrics 152-157, May 1973 2. Weary PE: A two year experience with a series of rural skin and oral cancer detection clinics. JAMA 217:1862-1863, Sep 27,
1971 3. Kanof EP: Experience with a skin cancer detection clinic at
a state fair. N Carol Med J 35:159-161, Mar 1974
4. Hall AF: Relationships of sunlight, complexion, and heredity 61:589-610, Apr 1950
to skin carcinogenesis. Arch Derm
Screening for Skin Cancer at a County Fair E. DORINDA LOEFFEL, MD, Chicago, and WILLIAM WATSON, MD, Stanford
Six skin cancer detection clinics were held at a county fair booth in Turlock, California during August, 1973. Examination of sun-exposed skin areas in 605 people showed potential skin cancer in 28.6 percent of people 25 years of age or older. Of the people examined, 135 were referred to their own physicians for follow-up diagnosis and treatment of skin lesions. EARLY RECOGNITION and successful treatment of skin cancer is a realistic goal, given the visibility of early malignant skin lesions and the ease of rapid diagnostic confirmation through skin biopsy. Diagnostic delay of the "sore that won't heal" seems inexcusable, but understandable, due to lack of pain coupled with cosmetic indifference, personal neglect and fear of going to a physician's office. General ignorance about skin cancer, transportation problems for geriatric patients and lack of convenient health care facilities also probably contribute to delay in diagnosis. To counteract such difficulties, efforts have been made in several areas of the country to "reach" people by taking cancer-detection units to unusual places. In Nebraska, a mobile house trailer with special examination rooms and x-ray equipment is used in screening geriatric patients for skin cancer as well as cancer of the mouth, larynx, breast, lung, uterus and colon.' In Virginia, several Saturday clinics have been held in rural areas for detection of skin and oral cancer among farmers.2 In North Carolina, a skin cancer detection clinic was operated at the 1972 State Fair, with special emphasis on educating large numbers of people From the Department of Dermatology, Stanford University Medical Center, Stanford. Submitted July 9, 1974. Reprint requests to: W. Watson, MD, Department of Dermatology, Stanford University Medical Center, Stanford, CA 94305.
about the dangers to skin of excessive sunlight ex-
posure.3 Most of these programs have depended on physician volunteers, along with promotional, organizational and financial support from the American Cancer Society. In August, 1973, a pilot skin cancer screening booth sponsored by the American Cancer Society and the National Program for Dermatology was operated for six days at the Stanislaus County Fair in Turlock, California. Turlock is a community of 14,000 people located in the hot, fertile San Joaquin Valley and serving a surrounding population of farmers and ranchers at very high risk for developing skin cancer. An estimated 50,000 people attend the fair at Turlock every year, so that detection of a large number of people with skin cancer could be anticipated if visitors to the fair could be persuaded to undergo skin examinations. Attention was drawn to the booth in advance through newspaper articles and contact with the Stanislaus County Medical Society. Posters, pamphlets and an audiovisual program about cancer detection helped to advertise the location of the booth. Cancer Society volunteers giving friendly reassurance that examinations were quick, free and painless helped popularize the booth. Skin examinations were done by five physicians from the Stanford University Dermatology DeTHE WESTERN JOURNAL OF MEDICINE
123
SCREENING FOR SKIN CANCER
Date
Name
middl e i niti al
Fi rst
Last
Address
Sex Age Occupation_
Phone
Birthplace_
Number of years lived in California
Race
Previous skin cancer
yes
no
Usual physican and address
Presumptive diagnoses (check and locate 1. 2. 3. 4. 5. 6. 7. 8.
on
anatomical diagram)
Actinic keratosis Basal cell carcinoma Squamous cell carcinoma Leukoplakia Bowen's Disease Melanoma Normal skin Other (specify)
-
Ccf R1 1'
Degree of actinic damage:
Z--t_
C~~~~~~~
mild moderate severe Examiner
Figure 1.-Registration form used in skin cancer screening booth.
Physician notified of abnormal skin findings by American Cancer Society on
(date) American Cancer Society Booth Stanislaus County Fair Turlock, California August 6-11, 1973
partment working on different evenings. A tiny examining room was formed with portable screens surrounding a single chair, goose-necked lamp and small cabinet. Only sun-exposed skin areas (face, neck, upper chest, arms and hands) were examined in most cases, so that it was not necessary for clothing to be removed. Other skin areas were examined upon request. The average examination took two to three minutes, with less time for children and longer times for complicated problems. TABLE 1.-Checklist Used in Making Presumptive Diagnosis 1. 2. 3. 4.
Actinic keratosis Basal cell carcinoma Squamous cell carcinoma Melanoma
124
5. Leukoplakia 6. Bowen's disease 7. Normal skin 8. Other (specify)
FEBRUARY 1975 * 122 * 2
Records were kept on cards filled in both by the physician and by the person being examined (Figure 1). After the visitor supplied personal information, the physician estimated the degree of sun damage (none, mild, moderate, severe) and checked off a presumptive diagnosis from a list of seven common lesions (Table 1). The location of suspicious lesions was noted on an anatomical sticker pasted to the card. Later, the presumptive diagnosis and the location of the lesion were recorded on a postcard that was mailed to the patient's usual physician. The postcard also contained an explanation: "Your patient was recently screened for skin cancer in the American Cancer Society Booth at the Stanislaus County Fair in Turlock. Abnormal findings were called to the
SCREENING FOR SKIN CANCER
= E
total number of patients examined per 5 year age span number of positive examinations for presumptive malignant and premalignant skin lesions
25
20
la 7E x
0
at
S
@a 10
0
P.
Si)
0
In
0
0.
S
S)
.
.0
0
in E
0
C
i
Vth
/
V(
VeVet
/VfV{
20 30 40 50 60 7o0 80 90 age range in years Figure 2.-Distribution by age of normalland abnormal examination results in men. 10
0
50
la
40 .
c
E x
30 b
0) 0
-
20
0
IN 0 .0
CY CY
E 10
t-
a-
$o
Male
one
di I
Ie 10
zd2&/ZVZZ4'ZIA
Results Community response to the booth was generally favorable, with most visitors expressing appreciation for the time and effort given by volunteers. Many people sought advice for specific skin problems, while others came because of curiosity or a desire to please a concerned spouse. A few people questioned the program's legitimacy and motives. Several also requested that records not be sent to their physicians, apparently from fear of offending them. A few physicians in the area opposed the booth on the principle that it represented "curbstone" medicine. Skin examinations were done on 605 people, including 222 men and 383 women, ranging in age from 3 to 89 years old. Distribution of normal and abnormal results of the examinations by sex and age group is shown in Figures 2 and 3. While 370 people had normal skin and 85 more had only minor skin problems, 149 had significant skin problems deserving medical attention. Of these 149 people, 135 were eventually referred for treatment to their personal physicians. In 14 cases, information was too incomplete to enable referral. Presumptive diagnosis of malignant and premalignant skin lesions was made in 125 people, including 63 men and 62 women, ranging in age from 25 to 89 years. Suspicious lesions included basal cell carcinoma in 49, squamous cell carcinoma or possible Bowen's disease in 11, leukoplakia in 8 and actinic keratosis in 88 people. Table 2 shows the exact distribution of lesions by sex. Most lesions were on sun-exposed areas, although one basal cell carcinoma and two squamous cell carcinomas were seen on legs. Leukoplakia was detected only on lower lips, as complete oral examinations were not attempted. Two types of potential skin cancer were present in 31 people, with actinic keratoses occurring together with TABLE 2.-Presumptive Clinical Diagnosis of Malignant and Premalignant Skin Lesions
at C
attention of the patient, who will hopefully contact you for advice in the near future. Additional information is available in our Modesto office."
Do E
L
20 30 40 50 60
70
so
90
age range in years Figure 3.-Distribution by age of normal and abnormal examination results in women.
Basal cell carcinoma ......... 24 Squamous cell carcinoma and Bowen's disease ........... 5 Leukoplakia ................ 7 Actinic keratoses* ........... 48
Female
Total
25
49
6 1 40
11 8 88
* In 31 people, actinic keratoses occurred along with basal cell carcinoma (19), squamous cell carcinoma (8) and leukoplakia (4).
THE WESTERN JOURNAL OF MEDICINE
125
SCREENING FOR SKIN CANCER TABLE 3.-Significant Nonmalignant Skin Lesions Age/Sex
6
Presumptive Diagnosis
9
15 9 19 19
9 9 9
20 20 9 23 24 26 30 43 46 47 59
9 9 9 9 9 9 9 9 59 9 61 9 62 9 62 64 99 69 71 99 75
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Dermatophyte infection-cheek Atopic hand eczema Irritated nevi on back Acne and tinea versicolor Tinea versicolor Nickel allergy and "mole"on labia (not examined) Irritated nevi on back Chloasma Seborrheic dermatitis-postauricular Bleeding nevus Syringomas Lichen simplex chronicus-forearm Xanthelasma
Xanthelasma Red nodule-tongue Giant skin tag vs. neurofibroma Blue nevus-forehead Stasis dermatitis Xanthelasma Flesh-colored papule-cheek Violaceous nodules-forearm Hutchinson's freckle vs. senile lentigo
basal cell carcinoma, squamous cell carcinoma or leukoplakia. The youngest age at which each type of lesion was detected was 25 for basal cell carcinoma, 28 for actinic keratosis, 39 for squamous cell carcinoma and 40 years old for leukoplakia. Grouping of lesions into five-year age groups showed peaks at age 45 to 50 for men and age 60 to 65 for women (Figures 2 and 3). No malignant or premalignant lesions were seen in people younger than 25 years of age. No melanomas were detected. Significant nonmalignant skin lesions were found in 22 people (Table 3) who therefore were referred for treatment. These included 21 women. Nine lesions were felt to warrant skin biopsy to enable exact identification.
Discussion Previous skin cancer detection clinics in Virginia and North Carolina had overall detection rates of 21.6 percent and 37.8 percent respectively.2'3 In this study the overall detection rate for potential skin cancer was 20.6 percent. If significant nonmalignant skin lesions were included, the detection rate increased to 24.3 percent. Therefore, almost one out of four skin examinations produced a significant finding. For people 25 years of age and older, the effective cancer detection rate was 28.6 percent, or 125 out of 438 examinations. Since no potentially malignant skin lesions 126
FEBRUARY 1975
*
122
*
2
were found under age 25, exclusion of the younger age group would seemingly save time and be medically safe except for melanoma detection. However, this might greatly hamper instruction of young persons about the hazards of sunlight and the value of protective clothing and sunscreens. Such advice is particularly important for Causasions with red or blonde hair, blue eyes and fair complexions-who form the group most at risk for developing skin cancer.4 No attempt was made in this study to verify presumptive diagnoses or trace individual followup treatment. While such measures are necessary to assure proper care and firm statistics, they require a great deal of volunteer time, perseverance and effort. It was hoped in this project that individual patients would take responsibility for seeking medical care and that physicians in the area would willingly examine and treat skin lesions called to their attention. Future skin cancer screening programs should probably limit examinations to people 25 years old or older, except for evaluation of specific skin problems such as changing "moles" in younger persons. Education about skin cancer and its relationship to prolonged sun exposure could perhaps be carried out in an adjacent area by a physician not involved in making examinations. Distribution of free sunscreen samples, as done at the North Carolina State Fair, would probably help draw visitors to the booth. Detection of oral cancer could easily be added to such a program, providing that sufficient space were available to accommodate a dental examination chair and proper light source. The benefits of such screening programs should be substantial, with early detection of skin cancer leading to prolongation of life and reduction of future required medical care. Possibly, the greatest long-term benefit could be cancer prevention through mass education concerning the hazards of prolonged sun exposure and the usefulness of sunscreens. Additional benefits to participating volunteers include the personal satisfaction of useful community service and the enjoyment of friendly interaction with local residents in a relaxed environment. REFERENCES 1. Lynch H, Lynch J, Kraff C: A new approach to cancer screening and education. Geriatrics 152-157, May 1973 2. Weary PE: A two year experience with a series of rural skin and oral cancer detection clinics. JAMA 217:1862-1863, Sep 27,
1971 3. Kanof EP: Experience with a skin cancer detection clinic at
a state fair. N Carol Med J 35:159-161, Mar 1974
4. Hall AF: Relationships of sunlight, complexion, and heredity 61:589-610, Apr 1950
to skin carcinogenesis. Arch Derm
